Rooted DOULA Collectivenew client FormThis is a more detailed form for clients who have hired a Rooted Doula to support them. About you Client Name: * First Name Last Name Client Pronouns: * Email: * Phone: * (###) ### #### Preferred method of contact: Phone Email Clients Zip Code: * Relationship Status: Please Select Single Married Domestic Partner Divorced Widow Other Living Arrangements: Please Select Self Parents With Partner Shelter Other How many people live in your household? This question is required if you are seeking financial assistance for the cost of services. Total Family Income: This response is required if you are seeking financial assistance to cover the cost of services. Please Select $0-15k $15,001-30k $30,001-45k $45,001-60k $60,001-80k $80,001 - 120k $120,001 - 140k $140,001-160k $160,001-180k $180,001-200k $200,001- and up About your needs: Services you are interested in (select all that apply) * Please note that most of our doulas are practicing virtually due to COVID 19. Be sure to select if you are interested in virtual and/or in-person support. Birth support Post-partum care Abortion care support Miscarriage support Stillbirth care Virtual support In-person support Estimated Due Date or Baby Date of Birth: * MM DD YYYY Describe your ideal caretaker or birth supporter: Please select the options that describe you best: First-time parent Experienced parent Parent of multiples Teen parent VBAC History of miscarriage/stillbirth History of infertility Other Have you had any complications with your current pregnancy? Please select Yes No N/A If yes, please explain in the space below: Have you had any prior pregnancies? Please select No Yes 1-2 Yes 3-4 Yes 5-6 If you have had prior pregnancies, were there complications we should know about? Are you currently receiving consistent prenatal care/services? Please select Yes No About your support circle Do you have an involved co-parent or partner? Yes No Describe their level of involvement: Please Select Absent Sometimes Co-parenting Very involved N/A Other Do you feel as if you have enough support around you? Whether they are friends, family or other loved ones Please select Yes No What does your support system currently look like? Social history The following questions help us better understand your current health situation. Here at Rooted Doula Collective -- we work to offer resources and services not just for pregnancy and birth, but for overall wellness and prosperity. If you do not wish to disclose this information, please select N/A. Current housing situation: Please select Inadequate Adequate In transition Overcrowded Feels unsafe None of the above N/A History of abuse: Please select Physical Sexual Emotional Does not apply to me N/A Mental health: Please select No concerns Prior history Currently in treatment N/A Physical health: Please select No concerns Moderate wellness Chronic illness N/A Food security: Please select No concerns Moderately concerned Very concerned Does not apply to me N/A Social services Please select I am not receiving any Women, Infants, and Children (WIC) Food stamps Public assistance Medicaid Housing assistance What community resources/services do you think you may need, if any? Check all that apply Housing Employment Social services Legal services Education Harm reduction services Other Thank you! You can expect a doula to reach out to schedule a consultation in 3-5 business days.
